Severe granulomatous reaction associated with hypercalcemia occurring after silicone soft tissue augmentation of the buttocks: a case report

The Autoimmune/Inflammatory Syndrome Induced by Adjuvants (ASIA), Associated with Renal Compromise and Cutaneous Calcinosis: A Case Report and Literature Review

The autoimmune/inflammatory syndrome induced by adjuvants (ASIA) was first introduced in 2011 to provide a more precise syndromic characterization of clinical manifestations observed in patients exposed to adjuvant substances such as biopolymers and silicone, among others. The clinical spectrum of this entity is variable, ranging from local involvement to potentially fatal immune-mediated systemic involvement. The interest in ASIA has grown in recent years, reinforcing diagnostic criteria and deepening the understanding of its pathophysiological behavior. This case report highlights a distinct range of clinical symptoms, such as general symptoms, advanced-stage chronic kidney disease, persistent hypercalcemia with suppressed parathyroid hormone (PTH), bilateral nephrocalcinosis, cutaneous calcinosis, and the presence of positive autoantibodies, emphasizing the significance of understanding this condition.

Acute pneumonitis and diffuse alveolar hemorrhage secondary to silicone embolism: A case report

RATIONALE

Polydimethylsiloxane, commonly referred as silicone, is an inert liquid compound used in esthetic procedures due to its durability and thermal stability, yet the application of non-pure silicone generates risks. One of the complications is systemic embolism syndrome which is presents with fever, hypoxemia, and progression to respiratory failure, diffuse alveolar damage and alveolar hemorrhage, as well as neurological alterations in one-third of the cases. Management is strictly supportive. We present the case of acute pneumonitis with alveolar hemorrhage after silicone injection.

PATIENT CONCERNS

25-year-old transsexual man, who consulted 48 hours after liquid silicone injection in the buttocks and trochanteric area, with progressive dyspnea and chest tightness, with rapid progression to respiratory failure.

DIAGNOSIS

Clinical diagnosis of silicone embolism was made. Chest x-ray and CT angiography showed diffuse alveolar infiltrates and pleural effusion without evidence of acute venous thromboembolism. Bronchoscopy plus bronchoalveolar lavage showed hemorrhagic fluid, 60% macrophages with hemosiderin in cytology and negative cultures.

INTERVENTION

Sedation, relaxation, pronation, and protective ventilation were implemented until hemodynamic stabilization; as well as IV steroids and antibiotics.

OUTCOMES

Clinical progress was slow towards improvement with resolution of radiological or physical abnormalities. Despite severity, the patient improved satisfactorily without late sequelae.

LESSONS

Silicone injection can trigger phenomena similar to that seen in fat embolism causing inflammation and immune response activation that lead to alveolar hemorrhage, diffuse alveolar damage, and acute respiratory distress syndrome. We reported pulmonary complications related to the illegal use of injected silicone for esthetic procedures.

Siliconomas of the lower limb: Tumour-like excision and reconstruction

Background:

Silicone oil injection can cause several complications including pain, cellulitis, abscesses, skin compromise, migration, embolism and multiorgan failure. Oil-infested tissue excision remains the solely treatment to prevent such complications.

Objectives:

The authors evaluate tumor-like excision of the oil-infested tissue as a treatment for patients experiencing silicone injections in the lower limbs, to both preserve aesthetic appearance and solve further risk of complication from silicone.

Methods:

Between January 2004 and January 2011 a total of 12 consecutive, nonrandomized female patients underwent surgical management of siliconoma of the lower limb. The mean age was 41-years, range from 22 to 61 years and all patients didn’t referred comorbidities. Eight siliconomas were located on the leg and 4 were on the thigh. The mean area of siliconoma was 35 cm², range from 25 to 60 cm². Each patient was evaluated by ultrasonography and EchocolorDoppler of the soft tissue and in order to achieve a “staging” of siliconoma.

Results:

Healing was uneventful in all cases. Three patients (25%) suffering hypertrophic scarring underwent further injection of corticosteroids to improve hypertrophic scars quality. Two patients (16.6%) required a further session of structural fat grafting to improve thigh's profile. All patients were satisfied with the cosmetic results and indispositions requiring medical therapy disappeared.

Conclusions:

Tumor-like excision and immediate reconstruction appears to be a safe and consistent surgical option that preserves aesthetic appearance for patients victims of illegal oil silicone injection of the lower limbs.

Silicone-Induced Granulomatous Reaction Causing Severe Hypercalcemia: Case Report and Literature Review

A 67-year-old woman presented to the hospital with complaints of abdominal pain. Physical exam was significant for signs of severe dehydration, mild epigastric tenderness and multiple non-tender hard nodules over her arms and thighs. Incidental finding of severe hypercalcemia led to negative workups for hyperparathyroidism, vitamin D intoxication, and malignancy. However, elevated levels of 1,25-hydroxy vitamin D raised the possibility of granulomatous diseases. Imaging and patient report revealed silicone-induced foreign body granulomatous reaction as the cause of hypercalcemia. Use of silicone for cosmetic enhancement of body contours can result in siliconomas, severe hypercalcemia, and complications. Treatment is unestablished for this condition. Increasing prevalence of cosmetic enhancement should prompt vigilance for this rare disease entity. Providers should counsel and educate individuals undergoing such procedures.

[Injected non-absorbable fillers in large volumes]

AIM

To present treatment strategy for large volumes of injectable non-absorbable 'shell-less' soft tissue fillers (vaseline, synthol, silicone etc.).

MATERIAL AND METHODS

The authors present an experience of surgical treatment of 8 patients who underwent injections of medical vaseline (breast augmentation, n=5) and synthol (muscles enlargement, n=3) and review of the current literature devoted to this problem.

RESULTS

Injection of large amounts (over 50 ml) of non-absorbable fillers into soft tissues is unacceptable and leads to numerous complications. Oil-based 'shell-less' fillers cannot be removed by minimally invasive techniques (puncture, mini-incisions, etc.) due to multiple diffuse lesions in the form of oleogranulomas (cysts of different size) and surrounding widespread inflammation and fibrosis of tissues. Surgery is the only adequate method. However, this approach is followed by scars and often tissue contour deformation. Migration of these fillers to other anatomical areas (from the neck to the lower extremities) significantly complicates the situation, treatment and results. In case of categorical refusal of patients from surgical treatment and no complaints, they should be properly informed about possible consequences and complications and dynamic medical supervision is necessary. Intraoperative ultrasound examination is useful for the control of radical removal of pathological areas. Timely removal of non-absorbable fillers allows to avoid serious complications and to achieve good aesthetic results.

SILICONE GRANULOMATOUS INFLAMMATION RESULTING IN HYPERCALCEMIA: A REVIEW OF THE LITERATURE

Objective

Silicone usage for cosmetic enhancement is common, although it is not approved by the U.S. Food and Drug Administration. Granulomatous inflammation leading to hypercalcemia is a rare complication. We present a case of non-parathyroid hormone (PTH), calcitriol-mediated hypercalcemia in a woman with a history of cosmetic injections.

Methods

Case report and review of the literature.

Results

A 48-year-old female with metabolic syndrome was evaluated for severe hypercalcemia (calcium >15 mg/dL). Laboratory tests revealed low-normal PTH, normal 25-hydroxyvitamin D, elevated 1,25-dihydroxyvitamin D, and hypercalciuria. Imaging studies, including a computed tomography (CT) scan of the lungs, was nonrevealing. Positron emission tomography/CT showed symmetric hypermetabolic subcutaneous stranding of bilateral gluteus and proximal thighs. She admitted to silicone injections in the buttocks 10 years prior. Her examination was unremarkable except for an intermittent pruritic rash over the right thigh. Labs revealed total serum calcium 11.3 mg/dL, PTH 18 pg/mL, 24-hour urinary calcium 509 mg, and PTH-related peptide 18 pg/mL. Serum and urine electrophoresis were normal, 25-hydroxyvitamin D was 47 pg/mL, and 1,25-dihydroxyvitamin D was 121 pg/mL. Angiotensin-converting enzyme level was 80 U/mL. A diagnosis of granulomatous inflammation resulting in calcitriol-mediated, PTH-independent hypercalcemia was entertained.

Conclusion

Silicone-induced hypercalcemia should be thought of in those with prior cosmetic injections. Tissue biopsy confirms the diagnosis, which is often delayed. We reviewed 19 cases with silicone usage and variable levels of hypercalcemia. Renal injury was common. One death was reported. Glucocorticoids, calcium restriction, and hydration have been used to treat calcitriol-mediated hypercalcemia but are not curative. Ketoconazole and bisphosphonates have been used with variable success. Surgical excision tends to be ineffective due to silicone migration. The treatment of this disorder is difficult and often ineffective.

Hypercalcemia associated with cosmetic injections: a systematic review

INTRODUCTION

Cosmetic injections with silicone and polymethylmethacrylate are not FDA approved for augmentation of body parts such as breast, buttock or legs, but they have been widely used for decades. Cosmetic injections can cause foreign body granulomas and occasionally severe and life-threatening hypercalcemia. We aimed to systematically analyze the published literature on cosmetic injection-associated hypercalcemia.

METHODS

We searched relevant articles on hypercalcemia associated with various cosmetic injections and extracted relevant data on demographics, cosmetic injections used, severity of hypercalcemia, management and outcomes.

RESULTS

We identified 23 eligible patients from 20 articles. Mean age was 49.83 ± 14.70 years with a female preponderance (78.26% including transgender females). Silicone was most commonly used, followed by polymethylmethacrylate and paraffin oil (43.48, 30.43, and 8.70% respectively). The buttock was the most common site followed by the breast (69.57% and 39.13% respectively). Hypercalcemia developed at mean duration of 7.96 ± 7.19 years from the initial procedure. Mean ionized calcium at presentation was 2.19 ± 0.61 mmol/L and mean corrected calcium at presentation was 3.43 ± 0.31 mmol/L. 1,25-Dihydroxyvitamin D (1,25(OH)₂D or calcitriol) was elevated while 25-hydroxyvitamin D (25(OH)D) and PTH were low in majority of cases. Hypercalcemia was managed conservatively with hydration, corticosteroids and bisphosphonates in majority of cases. Surgery was attempted in 2 cases but was unsuccessful. Renal failure was the most common complication (82.35% cases) and 2 patients died.

CONCLUSION

Hypercalcemia from cosmetic injections can be severe and life threatening and can present years after the initial procedure. Cosmetic injection-associated granuloma should be considered a cause of hypercalcemia, especially in middle-aged females presenting with non-PTH-mediated, non-malignant hypercalcemia, which is often associated with elevated calcitriol; however, it should be noted that calcitriol level may be normal as well.

Calcitriol-mediated hypercalcemia secondary to granulomatous disease caused by soft-tissue filler injection: a case report

Soft-tissue filler (STF) injections have been used worldwide for cosmetic reasons. In most cases, they are not approved by the United States Food and Drug Administration (FDA). Regulatory boards in Latin American countries do not allow the medical use of STF injections; however, these injections are still widely used. A case of calcitriol-mediated hypercalcemia with ectopic calcifications, chronic kidney disease, nephrolithiasis and calcinosis is presented. The reported case highlights the consequences of STF use, including calcitriol-mediated hypercalcemia secondary to granulomatous reactions years after an esthetic procedure.

ASIA syndrome, calcinosis cutis and chronic kidney disease following silicone injections. A case-based review

An immunologic adjuvant is a substance that enhances the antigen-specific immune response preferably without triggering one on its own. Silicone, a synthetic polymer used for reconstructive and cosmetic purposes, can cause, once injected, local and/or systemic reactions and trigger manifestations of autoimmunity, occasionally leading to an overt autoimmune disease. Siliconosis, calcinosis cutis with hypercalcemia and chronic kidney disease have all been reported in association with silicone injection. Here, we describe a case of autoimmune/auto-inflammatory syndrome induced by adjuvants, calcinosis cutis and chronic kidney disease after liquid silicone multiple injections in a young man who underwent a sex reassignment surgery, followed by a review of the literature. To our knowledge, this is the first report describing the concomitance of the three clinical conditions in the same patients. The link between silicone and the immune system is not completely understood yet and requires further reports and investigations with long-term data, in order to identify the main individual and genetical risk factors predisposing to the wide spectrum of the adjuvant-induced responses.

Severe Hypercalcemia Related to Silicone Granulomas, as Discovered by FDG-PET

Silicone injected for cosmetic purposes can provoke an inflammatory granulomatous response. In turn, silicone granulomas can lead to hypercalcemia, which is a rare, though potentially life-threatening condition. Hypercalcemia is a nonspecific laboratory finding with many potential etiologies. It may be difficult for clinicians to diagnose silicone-induced hypercalcemia, since the history of cosmetic silicone injections may not be elicited from the patient. Positron emission tomography using F-18-fluorodeoxyglucose (FDG-PET) can be used to evaluate patients with unexplained hypercalcemia as a means of searching for an occult malignancy or granulomatous process. FDG-PET findings may be the initial and perhaps only indication of silicone granulomas as the cause of hypercalcemia. Nuclear medicine physicians should have a low threshold for suggesting this diagnosis, particularly in the setting of unexplained hypercalcemia. This case report highlights the value of FDG-PET in diagnosing silicone granuloma-induced hypercalcemia.

Silicone-induced Granuloma After Buttock Augmentation

Liquid silicone is inexpensive, minimally antigenic, and likely noncarcinogenic. Its simplicity of use has made it popular as a soft-tissue filler in some parts of the world for patients seeking rapid soft-tissue augmentation of the face, breast, and buttocks. However, multiple reports describe the complications of silicone injections such as cellulitis, abscess, ulceration, and foreign body migration. We present an unusual complication of granulomatous reaction secondary to silicone injection for buttock augmentation, with a literature review of this entity and treatment options. Our patient was a 54-year-old woman who underwent bilateral buttock augmentation in the Dominican Republic using percutaneous injection of liquid silicone. She presented to our facility 1 year after this procedure with pain and inflammation of both buttocks. She was diagnosed with multiple silicone granulomas. Her symptoms completely resolved with a 3-week course of minocycline. Granulomatous reactions to silicone may occur months to years after the silicone injection. The incidence of such complications may be increased when nonmedical-grade silicone is used, and hence, when these procedures are performed in developing countries. Tetracycline antibiotics, especially minocycline, may be used to achieve sustained remission.

Gluteal Augmentation With Liquid Silicone of Unknown Purity Causes Granulomas in an Adult Female

Background:

A 39-year-old woman presented with a history of relapsing painful erythema and progressive fibrosis of the lower back. Upon questioning, the patient admitted to receiving liquid silicone (LS) injections for gluteal augmentation abroad and was diagnosed with silicone migration, granulomatous reaction, and fibrosis of the lower back.

Objective:

To review the history of LS injections for cosmetic soft tissue augmentation (STA) as well as its complications and potential treatments.

Methods:

The author reviewed articles that involved the use of LS for STA and summarized their findings.

Results:

The author summarizes the various treatments that have been described for inflammatory reactions following LS injection.

Conclusion:

The growth of cosmetic medical tourism and its inherent lack of after-care as well as patients’ ability to obtain restricted products at home raise the likelihood of encountering granulomatous or fibrotic reactions to fillers during consultations. Physicians should have a structured approach to these patients.

Resection of granulomatous tissue resolves silicone induced hypercalcemia

Because of the increasing trend of body contour enhancements with injections, implants, and fillers, clinicians should be on high alert for the possibility of silicone-induced hypercalcemia as one of the differential diagnoses in a patient with history of silicone use. Hypercalcemia as a result of silicone injections has been reported, and there is concern that there will be more cases given the popularity of cosmetic silicone. Cases involved a mother and daughter (70 & 55 years) who presented in 2013 with hypercalcemia after cosmetic silicone injections in 2007. Evaluation showed 1, 25-dihydroxyvitamin D-mediated hypercalcemia and progressive renal dysfunction; lymph node biopsy showed granulomatous silicone lymphadenitis. MRI of the pelvis revealed abnormal signal enhancement within the subcutaneous gluteal adipose tissue and enlarged inguinal lymph nodes. For persistent hypercalcemia and hypercalciuria, surgical resection of silicone material and granulomas is a successful approach to normalize the serum calcium level.

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One of the first reports of resolution of hypercalcemia by surgical intervention

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High possibility of silicone-induced hypercalcemia

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Surgical resection silicone material and granulomas is a successful approach.

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We aim to encourage the awareness of this condition among clinicians.